Healthcare Provider Details

I. General information

NPI: 1871294850
Provider Name (Legal Business Name): CHARLES KEOLA ABELLANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FAIRMONT SHOPPING CTR
PACIFICA CA
94044-1240
US

IV. Provider business mailing address

200 FAIRMONT SHOPPING CTR
PACIFICA CA
94044-1240
US

V. Phone/Fax

Practice location:
  • Phone: 650-355-5810
  • Fax: 650-355-5882
Mailing address:
  • Phone: 650-355-5810
  • Fax: 650-355-5882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTCH186885
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: